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About 4500 neural tube defects (NTD) occur every year in the European Union. Children with NTD will suffer from a lifelong disability often with inability to walk, hydrocephalus, learning problems, urinary infections and genital dysfunction. Up to two-thirds of these tragic cases can be prevented by folic acid supplementation.

USA and Canada implemented mandatory folic acid fortification of wheat flour and corn in 1998. A number of other countries followed the North American rules including Australia, most states in South America and many countries in the Middle East and Africa. In China and India, it is voluntary. EU is an exception, although the UK is considering fortification. I feel particularly ashamed of my own country Sweden, where food is not even voluntarily fortified with folic acid. Thus, many children could be saved from being severely disabled, and several more foetuses would not be aborted owing to the detection of NTD by ultrasound. The cleft palate could also, to some extent, be prevented.

In this issue of the Acta Paediatrica, Margaretha Jägerstad, professor emerita of food sciences, reviews the argument in favour of and against folic acid fortification. She reports that the daily folate intake among women is lower than the recommended levels. By fortification, most women will reach the recommended intake of folate (about 400 μg/day). With these levels there is no increased risk for cancer, which has been the strongest argument against fortification in the EU countries. Actually, it decreases the cancer risk, as the risk for cancer seems to be related in U-shaped fashion to folate concentrations. Only if a man eats more than five loaves of bread made of fortified flour every day, he may reach levels of folic acid that have been demonstrated to increase the risk of cancer in rats.

The European Food Safety Authority (EFSA) is still hesitant to recommend fortification with folic acid and requires more investigations. However, neither EFSA nor the global World Cancer review present data on increased cancer risk at physiological folate intake. Therefore, EU should act to implement folic acid fortification as NTD prophylaxis as soon as possible. I am convinced that the EU Commission would act promptly if a preventable error was detected in the Airbus plane or European cars, which would cause thousands of deaths and/or severe handicaps every year.